Provider Demographics
NPI:1023208360
Name:THOMAS H. WALTER DPM, INC.
Entity Type:Organization
Organization Name:THOMAS H. WALTER DPM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:860-599-4555
Mailing Address - Street 1:145 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:PAWCATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06379-1538
Mailing Address - Country:US
Mailing Address - Phone:860-599-4555
Mailing Address - Fax:860-599-1394
Practice Address - Street 1:145 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:PAWCATUCK
Practice Address - State:CT
Practice Address - Zip Code:06379-1538
Practice Address - Country:US
Practice Address - Phone:860-599-4555
Practice Address - Fax:860-599-1394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2020-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT13126213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC01464OtherMC GROUP NUMBER
CT0593930001Medicare NSC
CTC01464OtherMC GROUP NUMBER